Reducing ER Admissions with Care Transitions

National Council for Behavioral Health Tuesday, November 24, 2015

Psychiatric BoardersAdult Demographics

Larkin, GL, et al, Psych Services 2005; 56:671-677.

• 53 million mental health related visits• Increase from 4.9%-6.3% of all ED visits from 1992-2001• 17.1 to 23.6% visits per thousand over 10 years

– Increase in non-Hispanic whites, elderly and those with insurance

• Diagnoses– Substance-use disorders 22%– Mood disorders 17% – Anxiety related 16%

• Treatment 61% in ED

Psychiatric Boarders Pediatric Demographics

Sills, MR, Bland, SD: Summary statistics for pediatric psychiatric visits to US emergency departments, 1993-1999. Pediatrics 2002;110; 1-5.

• 1.6% of all ED pts in this age group• Non-white, teenage, female, live in NE or MW• Diagnoses

– Substance use disorder 24.2%– Anxiety disorder 16.6%– Attention deficit and disruptive 11.3%– Psychosis 10.8%

• Meds given in 47.1% • Admitted 19.4% • American Academy of Pediatrics and American College of

Emergency Physicians “support for increased mental health resources including improved pediatric mental health tools”

Psychiatric Boarders Burden of Care

• ED Administrators Schumaker Group: 2010 Survey Hospital Emergency Department Administrators. http://schumachergroup.com/_uploads/news/pdfs/ED%20Challenges%20and%20Trends%2012.14.10.pdf.

• 86% ED administrators indicated they are often unable to transfer pts • >70% of ED administrators report boarding > 24 hrs; 10% report > 1 wk• > 90 percent of survey respondents say this boarding reduces the availability

of ED beds

• Mental Health Patients Boarding in the ED Baraff LJ, Janowicz N, Asarnow JR. Survey of California emergency departments about practices for management of suicidal patients and resources available for their care. Ann Emerg Med. 2006 Oct;48(4):452-8, 458.e1-2. Epub 2006 Aug 21.

• 67 % of the emergency physicians reported a decrease in the number of psychiatric beds

• 23% send ED patients home without seeing a mental health professional due to a lack of resources

– 76% reported a lack of resources• Psychiatrist availability – 31% community, 3% rural and 81% teaching

Problems with Boarding

• Exacerbate underlying medical and psychiatric condition

• Little, if any, medical treatment• Little to no psychiatric treatment or therapy• Results in overuse of physical restraints, seclusion

and chemical restraints• Loss of hospital revenue

– Loss of $3,960,264 in one hospital in 2005• Falvo, 2007

• No difference in #s insured vs. uninsured boarded patients – Difference in the length of boarding

• Mansbach 2003

Psychiatric Boarders Limited ED Resources

• Limit psychiatric staff– Case workers, psychiatrists and social workers

• Limit comfort of the ED staff with evaluation of psych patients

• Need to perform medical clearance process• Need to “sober” up the patient• Limited outpatient referrals and unknown

community resources

Presented By:Dan Musgrove and Erin Kinard

WestCare Nevada, Inc.

Passed in 1986 the Emergency Treatment and Active Labor Act (EMTALA), requires all CMS-participating hospitals to provide emergency care to all individuals seeking care irrespective of ability to pay.

According to the Centers for Medicare and Medicaid Services (CMS), amounts to 55% of emergency care is uncompensated. (A.Adalja, M.D)

Across the nation the Mentally-ill and/or Intoxicated individuals creating over-crowding, long wait times and impacting care in the Emergency Rooms.

Adults with chronic mental-illness and/or intoxication exist in every community and are the “highest system users” costing the community millions of dollars.

Those in the Emergency Rooms, Law Enforcement, Emergency Medical Services, Ambulance, Paramedics, Jail, Court rooms, Mental Health hospitals, etc.

These individuals cycling through the systems of care, cost the community tremendous amounts including time and money.

Most times individuals cycle through these systems of care, several times a week, a month or sometimes even in a day.

What can be done to stop the cycle and wasting money?

In 2002, the Southern Nevada Regional Planning Coalition (SNRPC) recognized a report that a significant number of chronic inebriated and mentally ill persons were being held in emergency rooms for long periods of time due to an insufficient availability of mental health beds and other alternative detoxification facilities.

In 2003, the SNRPC agreed to create a centrally located Community Triage Center (CTC) of 50 beds for those mentally ill persons and chronic inebriates who are not in need of emergency room care. WestCare agreed to operate the CTC through their facility.

For the past twelve years, this center has been funded by the State of Nevada, local governments and area hospitals.

As an alternative to the Emergency Rooms, this is a mid-level of care for those with:◦ Intoxication/Substance Abuse◦ Mental Illness

Assessments for inpatient & outpatient services Initial case management services Referrals & service linkages Safe & effective treatment options for early intervention Discharge planning Clients served are often homeless, uninsured,

under-insured & indigent

The CTC’s are positioned to care for those who present with mental health and/or substance abuse issues as well as non-acute* medical conditions.

As an alternative level of care, they are equipped to handle the non-violent behavioral health and intoxicated clients in the community.

*Non-acute is defined based on medical status of the individual and the type of intervention indicated.

For those being removed from a public situation without formal charges, the Civil Protective Custody detainees, for example are taken to the CTC in lieu of the ‘drunk tank’ in jail.

Engagement in substance abuse or mental health treatment is also a potential outcome for this program.

Case Management and discharge planning are the keys to initiating change in this population.

Of this population seen in the ER, studies of the CTC populations in Nevada have shown 97% have no acute medical issues, only behavioral health problems.

They are held in the ER for assessments, medical clearance and due to the lack of available psychiatric beds in the community.

If released, there are concerns about liability, so ER’s are caught in the bind between discharging with no plan and opening-up beds for the medically-acute.

Staffing includes Registered Nurses, Nurse Practitioners, Case Managers, Counselors, a Medical Director and on-call Psychiatrists with the ability to accept patients 24-hours per day/ 7 days per week.

Medications are provided for those in need of stabilizing chronic but exacerbated medical conditions and for any medical issues during detoxification.

Low-level medical procedures can be performed, however CTC’s are not intended for that purpose.

PERSONIN

CRISIS

LAW ENFORCEMENT

EMERGENCY ROOM

EMERGENCY RESPONDERS

COMMUNITY PROVIDERS

MENTAL HEALTH

CTC

Several levels of intervention can occur with this one

person.

With the Community Triage Centerapproach, there is one intermediate level of care where all issues can be addressed

AVERAGE COST PER ENCOUNTER:

Ambulance: $1,267.00Hospital: $1,500.00 ($500.00/day x 3.5 days)First Responders: $1,000.00/incident

Per encounter estimate: $3,767.00

Las Vegas CTC admissions: 4,056 Average length of stay: 3.5 days Recidivism rate: 15%

Total costs: $1,726,480.67/year

If the same 4,056 clients had one encounter each with Emergency Services at $3,767.00, there would be $15,278,952.00 in costs to the community versus $1,726,480.67 for the same clients at the CTC!

Total Savings: $13,552,472.00

Erin Kinard MS, NCC, LCADCArea Director

WestCare Nevada, Inc.erin.kinard@westcare.com

Dan MusgroveGovernment Affairs,

WestCare Nevada, Inc.dan@dmadvocacy.com

www.westcare.com

Universal Health Insurance Mandates, And The Emergency Care Myth by Amesh Adalja, M.D retrieved August 12, 2013 from: http://www.forbes.com/sites/realspin/2012/10/08/universal-health-insurance-mandates-and- the-emergency-care-myth/